[104-10222-10040.pdf — page 114]
# DATE OF EMPLOYMENT (month, year)FRAC TITLE OF VOLA POSITIONANSWER ALL QUESTIONS BY PLACING "X" IN PROPER COLUMN23. Are you a citizen of the United States of America?    If "No," give country of which you are a citizen|     | YES | NO  || --- | --- | --- ||     | X   |     |24. Are you now, or have you ever been, a member of the Communist Party, U.S.A., the Communist Political Association, the Young Communist League, or any Communist organization?|     |     | X   || --- | --- | --- |27. Are you now or have you ever been a member of any foreign or domestic organization, association, movement, group, or combination of persons which is totalitarian, fascist, Communist, or subversive, or which has adopted, or shows, a policy of advocating or approving the commission of acts of force or violence to deny other persons their rights under the Constitution of the United States, or which seeks to alter the form of government of the United States by unconstitutional means?If your answer to 26 and/or 27 above is "Yes," state on a separate sheet attached to and made a part of the application the names of all such organizations, associations, movements, groups or combination of persons and date of membership. (Give complete details of your activities therein and make any explanation you desire regarding your membership or activities.) (See Instruction Sheet.)|     |     | X   || --- | --- | --- |28. Have you any physical handicap, chronic disease, or other disability?|     |     | X   || --- | --- | --- |29. Have you ever had a nervous breakdown?|     |     | X   || --- | --- | --- |30. Have you ever had tuberculosis?|     |     | X   || --- | --- | --- |If your answer to 28, 29, or 30 above is "Yes," give details in Item 39.31. Have you ever been barred by the U.S. Civil Service Commission from taking examinations of accepting civil service appointment? (If your answer is "Yes," give dates of and reasons for such debarment in Item 39.)|     | X   |     || --- | --- | --- |32. Does the United States Government employ in a civilian capacity any relative of yours (by blood or marriage) with whom you live or have lived within the past 24 months?    If your answer is "Yes," give in Item 39 for EACH such relative (1) full name; (2) present address; (3) relationship; (4) department or agency by which employed, and (5) kind of appointment.|     |     | X   || --- | --- | --- |33. Do you receive or have you applied for an annuity from the United States or District of Columbia Government under any retirement act or any pension, or other compensation for military or naval service?    If your answer is "Yes," give details in Item 39.|     |     | X   || --- | --- | --- |34. Are you an official or employee of any State, territory, county, or municipality?    If your answer is "Yes," give details in Item 39.|     |     | X   || --- | --- | --- |35. Have you ever been discharged (fired) from employment for any reason?|     | X   |     || --- | --- | --- |36. Have you ever resigned (quit) after being informed that your employer intended to discharge (fire) you for any reason?    If your answer to 35 or 36 above is "Yes," give details in Item 39. Show the name and address of employer, approximate date, and reason, in each case. This information should agree with statements made in item 19 - experience.|     | X   |     || --- | --- | --- |37. Have you ever been arrested, taken into custody, held for investigation of questioning, or charged by any law enforcement authority? (You may omit: (1) Traffic violations for which you paid a fine of $30.00 or less, and (2) anything that happened before your 16th birthday. All other incidents must be included, even though they were dismissed or you merely forfeited collateral.)|     | X   |     || --- | --- | --- |38. While in the military service were you ever arrested for an offense which resulted in a trial by deck court or by summary, special, or general court martial?    If your answer to 37 or 38 is "Yes," give details in Item 39, showing for each incident: (1) date, (2) charge, (3) place, (4) law enforcing authority or type of court or court-martial, and (5) action taken.|     | X   |     || --- | --- | --- |39. SPACE FOR DETAILED ANSWERS TO OTHER QUESTIONS. Indicate item numbers to which answers apply.| Item No |                                                                            || ------- | -------------------------------------------------------------------------- || 22      | China - Reside w/parents 1931-34.                                          ||         | Venezuela/Asst Att/1949-52                                                 ||         |                                                                            ||         | Mexico - Travel since-45                                                   ||         | Ecuador/Vice Consul/Guayaquil/1952-54                                      ||         | Visits to Colombia, Panama, Trinidad,Barbados, Brazil, Hawaii, Philippines ||         | Hong Kong                                                                  ||         | 7109. ongl & consul-at-degules 1956-59                                     |If more space is required, use full sheets of paper approximately the same size as this page. Write on each sheet your name, date of birth, and exam. Attach on inside of this applicationATTENTION: READ THE FOLLOWING PARAGRAPH CAREFULLY BEFORE SIGNING THIS APPLICATIONA false or dishonest answer to any question in this application may be grounds for rating you ineligible for Federal employment, or for dismissing you after appointment, and may be punishable by fine or imprisonment (U.S. Code, Title 18, Sec. 1001.). All statements made in the application are subject to investigation, including a check of your fingerprints, police records, and former employers. All information will be considered in determining your present fitness for Federal employment.CERTIFICATIONI CERTIFY that all of the statements made in this application are true, complete, and correct to the best of my knowledge and belief and are made in good faith.Signature of applicant![signature of applicant]Date 26, 1963.